Maximising the value of nudge units for global health
Authors: Harsha Thirumurthy, Alison M Buttenheim, Candice Chetty-Makkan, Sophie Pascoe
Journal: The Lancet Global Health (2023)

Since recognising that human behaviour is an important determinant of health outcomes, many organisations have established nudge units to identify inexpensive behavioural interventions (ie, nudges1Thaler RH Sunstein CR Nudge: improving decisions about health, wealth, and happiness. Penguin Books, New York2009Google Scholar) that can alter the behaviour of consumers, patients, and providers. WHO established its own behavioural science unit in 2021.2Ghebreyesus TA Using behavioural science for better health.Bull World Health Organ. 2021; 99: 755Crossref PubMed Scopus (1) Google Scholar Despite this proliferation, however, there has been little progress in applying behavioural science to health challenges in low-income and middle-income countries (LMICs). Most nudge units are based in high-income countries (HICs),3Organization for Economic Co-operation and DevelopmentBehavioural insights and public policy lessons from around the world: lessons from around the world.https://read.oecd-ilibrary.org/governance/behavioural-insights-and-public-policy_9789264270480-en#page1Date: 2017Date accessed: June 29, 2023Google Scholar and research agendas are often driven by behavioural scientists from high-income countries who seldom treat LMIC researchers as equal partners or invest in strengthening local behavioural science capacity.4Mughogho W Adhiambo J Forscher PS African researchers must be full participants in behavioural science research.Nat Hum Behav. 2023; 7: 297-299Crossref PubMed Scopus (2) Google Scholar, 5Chelwa G Does economics have an 'Africa problem'?.Econ Soc. 2021; 50: 78-99Crossref Scopus (8) Google Scholar The HIV epidemic in sub-Saharan Africa is an ideal case for collaborative nudge units. Nearly 25% of people living with HIV are either unaware of their status or not taking treatment regularly, and about 1·5 million new infections still occur every year.6UNAIDSIn danger: UNAIDS global AIDS update 2022. Joint United Nations Programme on HIV/AIDS, Geneva2022Crossref Google Scholar These numbers suggest that behaviour matters, and innovative, behaviourally informed programmes and interventions are needed to end the HIV epidemic. This need was recognised in 2022 as a new behavioural science strategic priority for the US President's Emergency Plan for AIDS Relief, the US programme that funds many HIV programmes globally.7US President's Emergency Plan for AIDS ReliefFulfilling America's promise to end the HIV/AIDS pandemic by 2030. US Department of State, Washington DC2022Google Scholar In 2020, we established Indlela (meaning the path in Zulu), a nudge unit to build behavioural science capacity in South Africa and design behavioural interventions that improve HIV outcomes. In this Comment, we describe lessons from Indlela that can inform ongoing efforts to integrate behavioural science into health programmes in LMICs. Strengthening the capacity of local researchers and implementers in behavioural science has been a major priority of Indlela. To achieve this outcome, we have offered behavioural science training for Indlela's core team (four PhD-level staff, three masters-level staff, and one programme coordinator) through didactic workshops. In addition, we have provided support for staff to take courses run by organisations other than Indlela, and we have led behavioural science workshops for researchers and staff at South African universities and health-care delivery organisations. We have also adopted a learn by doing approach, in which Indlela researchers work closely with South African organisations to codevelop low-cost, light-touch interventions that tackle specific challenges in HIV service delivery (eg, low retention in care). Six projects have been jointly undertaken by Indlela staff and partner organisations (table).TableIndlela projects that test HIV-focused nudges in South AfricaProblemsRelevant behavioural science principles8Bernheim BD DellaVigna S Laibson D Handbook of behavioral economics–foundations and applications 2. North Holland, Amsterdam2019Google Scholar, 9Buttenheim A Thirumurthy H Behavioural economics and health.in: Detels R Abdool Karim Q Baum F Li L Leyland AH Oxford textbook of global public health. Oxford University Press, Oxford2021: 381-390Google Scholar, 10Hanoch Y Barnes A Rice T Behavioral economics and healthy behaviors: key concepts and current research. Routledge, London2017Crossref Scopus (0) Google ScholarProposed nudgesStudy design, sample sizeHIV preventionLimited engagement with the VMMC programmeHassle factors, social proof, salience, and framingSimplifying the form design for a mobile-based application to make VMMC bookings feel easy, salient, and appealingNon-experimental study design, ≥99 000 app usersHIV testingLow demand for HIV testing at local clinicsStigma, endowment effect, and loss aversionBrochures that promote combining HIV services with other desirable health screening services and emphasising the monetary value of the free HIV testRandomised controlled trial, 12 000 adultsRetention in care for PLWHLow levels of sustained engagement in HIV care among PLWHPresent bias and choice overloadA visual aid that uses bead bottles to explain the effect of HIV treatment on viral loadMixed methods, 80 PLWHRetention in care for PLWHHigh number of missed clinic appointments for PLWHLoss aversion, social norms, altruism, and framingOne-way text messages that use behavioural science principles to promote clinic attendanceRandomised controlled trial, 1600 PLWHRetention in care for PLWHLow levels of sustained engagement in HIV care among PLWHThe fresh start effect11Dai H Mao D Riis J et al.Effectiveness of medication adherence reminders tied to "fresh start" dates: a randomized clinical trial.JAMA Cardiol. 2017; 2: 453-455Crossref PubMed Scopus (4) Google ScholarFresh start text messaging using temporal landmarks to encourage return to HIV care across three study groupsRandomised controlled trial, 9630 PLWHRetention in care for PLWHAmbiguous referral path for PLWH receiving HIV treatmentPresent bias, choice overload, ostriching,12Golman R Hagmann D Loewenstein G Information avoidance.J Econ Lit. 2017; 55: 96-135Crossref Scopus (277) Google Scholar optimism bias, and ambiguity aversionProvide adherence score cards to identify risk for missing a visit and behaviourally informed treatment referrals for timely clinic visitsNon-experiemental design using difference-in-differences, 1400–2400 PLWHVMMC=voluntary medical male circumcision programme. PLWH=people living with HIV Open table in a new tab VMMC=voluntary medical male circumcision programme. PLWH=people living with HIV Indlela has also placed an emphasis on rapid evaluation methods to learn whether nudges are effective. Most projects were completed in less than 8 months, used randomised trial designs, and cost less than US$50 000 to implement. These projects are different from other conventional trials of behavioural and biomedical interventions that are longer and costlier because they focus on distant endpoints or rely on primary data collection. Instead, our projects typically had proximal behavioural outcomes strongly associated with biological outcomes (eg, attending clinic visits, which is associated with viral suppression) and used routine data. Nudges are ideally tested inexpensively and rapidly within established programmes serving thousands of individuals. However, this process can be challenging when electronic health records are insufficient, poorly integrated, or difficult to obtain. Timely approval from research ethics committees can also be a barrier to rapid testing, even when the nudges are light-touch interventions with minimal risks to participants. Additional engagement with policy makers and research ethics committees is essential for rapid-cycle innovation. As global evidence about effective nudges accumulates, there is a temptation to simply duplicate interventions that worked for different settings, populations, or problems. However, the risk of failure can be high without first identifying the reasons why people do not engage in specific health behaviour, such as getting tested for HIV or engaging in HIV care. To address this challenge, Indlela developed and deployed the NUDGE behavioural design framework, captured in a handbook13IndlelaThe NUDGE handbook: a practical guide to behavioural design based on the NUDGE framework. Indlela, Johannesburg2022https://indlela.org/nudge-handbook/Date accessed: July 1, 2023Google Scholar that offers a map for understanding behavioural challenges through rapid contextual inquiry and designing user-centred interventions. It is extremely difficult to introduce and test nudges within health programmes without an institutional champion. We found considerable heterogeneity in the willingness of organisations to develop and test nudges. Nudge units must cultivate champions for their work within governments and organisations. Creating a community of researchers and implementers can also be useful for facilitating dissemination of behavioural science resources and methods. There is evidence that nudges often have small effects when implemented at scale (although they remain highly cost-effective due to their low cost).14DellaVigna S Linos E RCTs to scale: comprehensive evidence from two nudge units.Econometrica. 2022; 90: 81-116Crossref Scopus (61) Google Scholar Nudge units should communicate the importance of identifying highly cost-effective solutions that are easy to implement. They should also explain that null findings are informative in revealing which interventions do not warrant resources. Behavioural science insights remain underutilised in places with the poorest health outcomes and fewest resources. Many of the challenges faced by Indlela offer important lessons for nudge units in LMICs. Indlela's work in the past 3 years has provided a widely applicable model for closing this gap in applying behavioural science to health challenges between LMICs and HICs. The model rests on strong collaborations with local researchers and strong partnerships with organisations engaged in health service delivery. Expanded use of nudge units in LMICs could, therefore, give rise to more behaviourally informed programmes that ultimately achieve better health outcomes. This work received funding from the Bill & Melinda Gates Foundation (INV-008318). We are grateful for the important contributions of Indlela team members to the various projects and activities led by Indlela. We declare no competing interests.